Healthcare Provider Details

I. General information

NPI: 1366554461
Provider Name (Legal Business Name): ROGER F YOUNG O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3465 PIONEER PKWY STE 5
WEST VALLEY CITY UT
84120-2079
US

IV. Provider business mailing address

3465 PIONEER PKWY STE 5
WEST VALLEY CITY UT
84120-2081
US

V. Phone/Fax

Practice location:
  • Phone: 801-966-0081
  • Fax: 801-966-0218
Mailing address:
  • Phone: 801-966-0081
  • Fax: 801-966-0218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4780952-9934
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: